Learn about front-line clinical informatics, clinical workflow design, and EMR implementation with an experienced CMIO. Open discussion is encouraged, education is a priority. All opinions are strictly my own.

Wednesday, August 18, 2010

The CMIO's checklist

So as someone who thinks a lot about the informational flows behind a hospital's day-to-day operations, I read a lot about people who are having challenges with "EMR governance issues".

The governance issues you hear about are basically related to change management and implementation issues. After you have an EMR, your training needs expand dramatically. You may need to engineer your paperwork differently. You have workflow issues to contend with, and decision support issues to tackle.

And the committee structure you had before your EMR may not hold up under the new workload demands. Make too small a committee, and you may not get the right input. Make too large a committee, and you may never be able to make a decision.

If the committee charters aren't well-designed, some committees will be overburdened, while others are looking for work to do.

And if you don't have the support to implement your basic tools, then the "ejection fraction" of your committees will drop. (E.g. the committee will decide on a new policy, but if nobody knows about the new policy, then the committee can make lots of decisions that don't really get executed on the floor.)

In short - it helps if you lay out a strategy for how to deal with all of these issues.

So I created this simple little tool, to help a CMIO (or CMIO-like person) figure out how to help orchestrate the "overhaul" to meet your new needs. I affectionately call it, "The CMIO's Checklist". (See the spreadsheet above for an idea of how to build your own.)

With this tool, you first have to come up with a list of your common paperwork design challenges. As an example, most hospitals generally struggle with the timely design, testing, approval, publication, and implementation of the following :

Procedures - Tools which include the detailed steps on how to achieve an organizational standard or defined goal. Typically published attached to a policy statement or in a separate procedure manual.

Guidelines - Tools more flexible and negotiable than a policy that are used to outline desired actions and outcomes of therapy.

Clinical Protocols (ON/OFF) - Tools used to standardize and automate care for a common clinical scenario, containing those conditional (IF/THEN) statements that allow a nurse, pharmacist, or other licensed medical professional to start / modify / stop a patient care order on behalf of a physician. All conditional (IF/THEN) statements in a protocol should refer to a discrete, well-defined data element. Protocols are primarily activated/deactivated by a physician order, or in some scenarios by a clinical policy. Common examples include : Heparin Protocol, alcohol protocol, PPI substitution protocol, etc. Protocols are typically published through a printshop or an electronic site.

Order Sets - Tools which include a grouping of orders which can be started / modified / stopped by a physician, used to standardize and expedite the ordering process for a common clinical scenario. Typically categorized as either admission order sets, diagnosis order sets, or convenience order sets, and commonly published either through a printshop or an EMR.

Orders - Tools used to instruct a licensed person to deliver a defined type of care to a defined patient at a defined time in a defined manner for a defined duration. Medication orders, referring to the delivery of medications, are typically compiled in a medication formulary and are commonly published via printshop, electronic site, or EMR.

Clinical Documentation - Tools used to record and sometimes transmit information about a patient's history, activities, therapies, and responses in time, legally authenticated by a licensed medical professional. Commonly includes notes, checklists, forms, flowsheets, tables, fields, images, movies, and other media. Clinical documentation is typically published through a printshop or an EMR.

Templates - Tools that help expedite and standardize the creation of a document.

Staff Education Modules - Tools used to educate staff about a common clinical scenario, often including text, slides, videos, recordings, and other media. All staff education modules will include at least three competency questions. Typically published through a printshop or an electronic site.

Patient Education Modules - Tools used to educate patients about a common clinical condition or activity, often including text, slides, videos, recordings, and other media. Follow-up questionnaires are recommended. Typically published through a printshop or an electronic site.

Staff Schedules - A tool used to define which staff member(s) is/are responsible for a specific type of care at a defined date and time. Typically published through a printshop or an electronic site.

Then, going down the left-hand border of the CMIO checklist spreadsheet, are the following questions that everyone goes through when creating any tool:

Who codes this tool? (Who comes up with the coding scheme for this tool?)

What coding schema do you use? (E.g. a number like #2.12 or ABC-123?)

Who publishes this tool? How will your staff be able to find it to use it? In a common place?

Who tracks this tool? (What database tracks the tool, it's code, and its approval date?)

Who educates/implements this tool? (Who is responsible for spreading the word that a new tool has entered your clinical arena?)

Who monitors this tool? (Who looks at the tracking database and checks your quality data to look for problems with the tool or its design process?)

Building and completing a CMIO's checklist is a good way to :

Generally figure out where your informatics issues may arise, after you go-live with your EMR.

Generally figure out what committee(s) you will need to approve the maintenance of these tools, and how to build those committees.

Help your committee chairpeople to better define their charters.

Help your middle managers know who is responsible for each part of each tool, when they need to make changes to the clinical setting.

Help the people who design these tools understand the definitions, so that you don't have the "feature bleed" problem I've talked about in previous posts.

Help employees understand the role(s) they play in the overall functioning of your organization.

You will probably want to try completing one of these BEFORE you go-live with your EMR. If you don't, you may have to adjust your governance issues AFTER your go-live.

Remember - Every hospital will have slightly different definitions of these tools, and fill in different titles and committees into each of these boxes. Why? Because unfortunately, there are not universally standard policy-worthy definitions for each of these tools - CMS and Joint Commission curiously don't seem to endorse definitions - I'm not sure why. (What I've written above is just my own example - You may need to adjust the definitions to suit your needs.)